Health system governance in the Arab world: A case study of six-countries

There is limited research on health system governance (HSG) in Arab countries. At a time of demands for more accountability and responsiveness to citizens' demands, HSG will become an increasingly important issue for governments and non-governments actors alike. We report the results of a regional study in six Arab countries (Egypt, Jordan, Lebanon, Syria, Sudan, and Tunisia) to assess HSG based on a novel analytic framework developed by the Eastern Mediterranean Regional Office of the World Health Organization. The framework poses questions for each of 10 principles – strategic vision, consensus and participation, rule of law, transparency, responsiveness, equity and inclusiveness, efficiency and effectiveness, accountability, intelligence and information, and ethics – at three levels: national, health policy formulation, and health policy implementation. Data were collected using mixed methods. Results, mapped to a matrix of the 10 principles across three levels, show some areas of strengths but important and pervasive deficiencies. Based on qualitative analysis, three key functions are prioritized: Strategic vision, transparency, and accountability. For example, there is incongruence of objectives between the strategic vision, operational plans, and the degree to which these get implemented; mechanisms to monitor transparency on the rationale of resource allocation are not well defined; and the culture of accountability to the public is not well entrenched. The country studies demonstrate these areas to be closely intertwined and influence health system performance. The recommendations for strengthening HSG concern building the evidence base on HSG, strengthening the role of the state and non-state actors, and tackling corruption.